FLU JAB BOOKING REQUEST

Complete this form if you are eligible for a flu jab, you will have received an invitation. Select your available timeslots and we will book the soonest appointment possible. We will text you the time of the appointment, if it is not suitable, call us to rearrange.

Please complete all necessary fields.

Select all timeslots you could attend for the flu jab:

Mon

Tue

Wed

Thu

I understand this form is not for Urgent Care. I am happy for Chartfield to contact me as appropriate and for this information to be entered into my medical record. I am submitting this information for myself or as the authorised proxy of someone else.

I understand that if I am at all unwell in the week before my appointment, I must cancel/rearrange as appropriate.

CHARTFIELD SURGERY

DO NOT ATTEND THE SURGERY UNLESS INSTRUCTED BY A CLINICIAN. FACE COVERINGS ARE MANDATORY.

FLU JAB BOOKING REQUEST